NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective July 9, 2004, reorganized
the Cabinet for Health Services and placed the Department for Medicaid Services
and the Medicaid Program under the Cabinet for Health and Family Services. The
Cabinet for Health and Family Services, Department for Medicaid Services has responsibility
to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet, by
administrative regulation, to comply with any requirement that may be imposed,
or opportunity presented, by federal law for the provision of medical
assistance to Kentucky's indigent citizenry. This administrative regulation
establishes the provisions relating to coverage of ambulance transportation
services to access a medical service for which payment shall be made by the
Medicaid Program.

Section 1. Definitions. (1)
"Ambulance transportation" means ground or air transportation
provided at advanced life support level or basic life support level by a
carrier licensed by the Kentucky Board of Emergency Medical Services.

(2) "Appropriate medical facility or
provider" means a local medical provider other than an emergency room of a
hospital who can provide necessary emergency care if a hospital emergency room
is not located within the medical service area.

(3) "Attending physician" means
a physician who provided medical care to the recipient at the time ambulance
transportation was needed and may include:

(a) The physician that the ambulance
provider was in contact with to determine where the recipient needed to be
transported for immediate care;

(b) The physician at the facility that
treated the patient on arrival from the ambulance transportation;

(c) The physician at the care facility
that recommended the recipient be transported to another facility for care not
available at the original care facility; or

(d) The physician at a nursing facility
that determined that the recipient needed to be transported to a hospital.

(4) "Department" means the
Department for Medicaid Services or its designated agent.

(5) "Medical service area"
means a recipient's county of residence or a contiguous county.

(6) "Medically necessary" or
"medical necessity" means a covered benefit is determined to be
needed in accordance with 907 KAR 3:130.

(7) "Other medical
professional" means a physician assistant, advanced registered nurse practitioner,
licensed nurse, or qualified mental health professional who is approved to
practice by the appropriate professional licensure board.

Section 2. Conditions of Participation.
(1) A participating ambulance transportation provider shall comply with the
terms and conditions established in:

(b) The recipient is traveling to or from
a Medicaid-covered service, exclusive of a pharmacy service; and

(c) The service is the least expensive
available transportation for the recipient's needs.

(2) A nonemergency ambulance service
provided outside the medical service area shall be covered if:

(a) The criteria specified in subsection
(1) of this section are satisfied;

(b) The medical service required by the
recipient is not available in the medical service area; and

(c) The recipient is referred by a
physician.

Section 5. Documentation Required for
Determination of Coverage. The necessity for an ambulance transportation
service shall be:

(1) Determined by the department; and

(2) Based upon a statement of medical
necessity by an attending physician which shall:

(a) Be maintained on file by the
transportation provider for a period of five (5) years; and

(b) Include the following information:

1. Verification by the provider of the:

a. Date of ambulance service;

b. Patient's name;

c. Patient's Medicaid identification
number;

d. Patient's address;

e. Origin of ambulance service; and

f. Destination of ambulance service; and

2. A signed and dated statement by the
attending physician, or other medical professional carrying out the orders of
the attending physician, which verifies the patient's diagnosis and whether or
not the patient:

a. Received treatment in an outpatient
setting following transport;

b. Required admission to the hospital
following transport;

c. Transferred from one (1) medical
facility to another;

d. Was confined to bed before and after
transport;

e. Required movement by stretcher; or

f. Had a medical condition which
contraindicated transportation by means other than an ambulance.

Section 6. Appeal Rights. (1) An appeal
of a department decision regarding a Medicaid recipient based upon an
application of this administrative regulation shall be in accordance with 907
KAR 1:563.

(2) An appeal of a department decision
regarding Medicaid eligibility of an individual shall be in accordance with 907
KAR 1:560.